Get Off Your High-Horse, Damn!

quote-i-think-there-is-a-tendency-for-people-to-get-rigid-and-caught-up-in-their-beliefs-of-matisyahu-93-5-0573Matisyahu. (n.d.). Retrieved November 08, 2017, from Web site:

If I hear just one more “professional” in the mental or behavioral health field (or worse, in the field of substance use disorders) state that Medication-Assisted Treatment (MAT) becoming more available and having to be covered by insurance companies is some horrendous thing, I’m going to lose it! I don’t understand, with all of the information so readily available via the internet, why the idea that MAT is simply replacing one drug with another persists. Why do these “professionals” continue acting like these people suffering from opioid use disorder are just coming into treatment to continue getting high. Are you kidding me? Do you HONESTLY think that ALL of the people working in these clinics are no better than DRUG DEALERS??  Wouldn’t we HAVE to be if that was the case? Your information is decades behind…PLEASE catch up!

I wonder how many of the people knocking MAT have prescriptions in their medicine cabinets for some chronic medical issue or another. High blood pressure meds, insulin…these keep an individual from having the symptoms of his/her illness. Guess what? So do MAT medications. In MAT, we aren’t getting patients high, we’re getting them normal. The medication keeps these patients from having the flu like symptoms that occur when they do not have the substance acting in their system. Let me be clear, opioid withdrawal is not like some mild flu, it is like the worst case of flu you have ever had…multiplied by a factor of 12…and it is UNRELENTING.

I can hear naysayers arguing, “but high blood pressure and diabetes aren’t the same as opioid addiction. Those addicts do it to themselves!” Well, some people with high blood pressure cause it by having a not-so-healthy diet….do they not deserve treatment? Someone that acquires lung cancer because he/she smokes like a chimney for his/her entire life…should we deny those patients treatment as well, because they “did it to themselves?” Opioid Withdrawal IS a medical issue, and if medication can treat it, why do some people act like people suffering from opioid use disorder have some kind of moral defect for taking advantage of the fact that it is offered? Not all opioid “addicts” start taking opioids for some mental escape. Many of the people in MAT end up there because they become dependent after being in treatment for chronic pain management, and get kicked out because they begin to abuse it because tolerance makes the dose they are prescribed not as effective. I wish people would stop and think about what these opioid “addicts” face when they decide to seek treatment. Many of them do not seek treatment because of the stigma attached, a stigma which behavioral and mental health workers, and substance use disorder workers SHOULD BE trying eradicate, but make worse by their JUDGMENT-Y posture on MAT! SHAME! You people SHOULD know better. If you don’t, you SHOULD–do your job and get current on the latest research! Being Mr./Ms. JudgeyMcJudgeyPants helps NO ONE, and actually DETERS people who desperately NEED treatment from seeking it. So…get off your high-horse, damn!


Me, Me, Me


Okay, I just need to rant for a minute…

Why do some people think that everything revolves around them? When did common courtesy become uncommon? I guess what I’m really asking is…WHAT THE HELL IS WRONG WITH PEOPLE???

That would be a long list, wouldn’t it? I’m not that old, but I do remember a time when people were actually decent to each other. I shi…oops, I mean…kid you not. Imagine… people opening doors for each other, people driving as if they understand that there are, in fact, other drivers sharing the road, people not having a loud conversation in the middle of the movie theater while the main feature is playing, people offering help…with no expectation of a returned favor! Mind boggling, isn’t it?

How did we get here?  Is it a result of dumbing-down school curricula over decades–a sort of ignorance of decency? Is this the consequence of everybody-gets-a-trophy entitlement? Did it arise from the ever-increasing popularity of the YouTube-ready clips of people “showing out?” When did that become entertaining, and what does that say about us? When did we begin to stop valuing each others’ humanness?

Don’t have a cow; I’m not making sweeping generalizations. I KNOW there are still kind people in the world, but you have to admit that they are getting more and more difficult to find, and there are many more observable instances of unkindness. It’s unfortunate. I wish that weren’t the case.

I’m no Pollyanna, but there has to be a way to remedy this. I’ve always said, “There’s no cure for a**hole that doesn’t end in prison-time,” but seriously, there has to be something we can do. Maybe a nation-wide movement…Down with D-bags! …Well, that’s not very family-friendly, but…we’ll come up with the name later…in the meantime, I guess I’ll have to do my part by continuing to act right, even when others do not, by taking random and frequent opportunities to show others kindness, even when they cannot return the favor, and by remembering to add to the solution, and not to the problem.



A Little Diversion


Medication-Assisted Treatment (MAT) facilities have struggled for a long time with some patients using their medication as a source of supplemental income. This happens more often than you would expect, and not just at methadone clinics. It happens at pain management clinics, and it happens at regular physicians’ offices. Selling one’s prescribed medications is called diversion, and it is a criminal offense.

You would think that it would be more likely to occur at a place like a methadone clinic. After all, those people are addicts, of course they engage in illegal activity. Well, think again. People suffering from addiction are not, in fact, the only ones engaging in this behavior. In fact, you likely know someone that has done it, or is currently doing it to make some extra cash. It isn’t difficult these days to obtain a prescription for pain meds, or for anxiety meds. These are among the most frequently diverted medications. And, if it is done through a physician’s office, there is little danger of the physician finding out. There really are no safeguards in place to prevent diversion at physicians’ offices, as there are at methadone clinics and other MAT facilities.

At MAT facilities, there are protocols in place to minimize diversion. The first is the inability to come into treatment and leave with medication to take home with you right away. In MAT, it takes time to earn takeout medication privileges. Patients are required initially to take their medication daily in front of the pharmacist at a dosing window. They have to be regularly monitored by various treatment team members for signs of over-sedation, and are monitored via random weekly urine drug screens for at least the first month. They are also required to see their counselor very regularly for addictions therapy and ongoing counseling sessions throughout the treatment episode.

Once a patient reaches a stabilizing dosage and begins testing negative for illicit substances, he/she is eligible to begin doing random urine drug screens once per month. It is at that point (usually after about a month in treatment) that the treatment team  examines the patient’s individual progress to determine if he/she is ready to have the first level of takeout medication, one takeout. The patient is instructed prior to the start of each new “phase” regarding the handling of the medication, the dangers of taking it in ways other than prescribed and of taking other substances or OTC medications with the medication, and in the consequences of mishandling or misusing the medication. If the patient continues to be compliant in treatment for the subsequent ninety days, continuing to test negative for illicit substances, continuing to see the counselor regularly, and continuing to have no legal issues relating to drug use and no behavioral issues at the facility,  he/she is again examined for eligibility and readiness for the next “phase,” or takeout level, two takeouts. After another ninety days of continued compliance, the patient is again examined for eligibility and readiness for the next “phase,” three takeouts. After another ninety days of continued compliance, the patient is again examined for eligibility and readiness for the next “phase,” six takeouts, meaning he/she attends clinic once per week. After another ninety days of continued compliance, the patient is again examined for eligibility and readiness for the next “phase,” thirteen takeouts, meaning he/she attends clinic once every two weeks.

The purpose of slowly increasing the allowance of takeout medications is twofold: to help the patient to avoid the addictive impulse to take more medication than he/she is prescribed, and to limit the patient’s ability to divert his/her medication. During the “phase-up” process, patients are taught to manage cravings and triggers, and taught how to handle having medication on hand without abusing it. Higher “phase” patients are still required to attend regular counseling sessions, and submit to regular random urine drug screens. It is worth noting that if, at any point in treatment a patient begins testing positive for illicit substances while he/she has takeout medication, the counselor will, depending on the situation, reduce or eliminate the number of takeouts and make the patient attend clinic more frequently for closer monitoring, and the patient will resume a weekly random urine drug screen schedule until he/she begins testing negative for illicit substances once again.

The second protocol is regular monitoring for diversion. To that end, patients having a higher “phase” are randomly phoned at least twice per year for a bottle recall. The patient is phoned in the middle of a pickup cycle and told to return to the clinic within 24 hours of the call. He/she is told to bring all bottles of medication with him/her, both empty and full. An observed drug screen (one in  which a counselor of the same sex, or a medical staff member goes into the restroom with the patient) is done when he/she arrives to ensure that the patient is not bringing urine in, or falsifying urine drug screen results in any way. If the patient is selling and not ingesting the medication, the observed urine drug screen results would show negative (or a lower level)  for the prescribed medication. After completing the observed urine drug screen, the patient is brought to the dosing window by the counselor, and the pharmacist inspects all of the medication bottles. The patient is then given his/her dose for that day and is instructed to medicate at the dosing window. If the seal on any of the remaining bottles is broken, if any of the medication is missing or appears to have been tampered with, it is considered a failed bottle recall and the patient is required to attend daily and begin the “phase-up” process all over again. If a patient does not answer the bottle recall phone call, does not check any messages left by the counselor, or just does not show up to complete the recall, it is considered a failed bottle recall and the consequences (loss of takeout privileges) is the same. Some MAT facilities will also require a patient to bring in any regularly prescribed medications with him/her to also have a pill count during a bottle recall to ensure that he/she is taking his/her outside medications correctly to monitor for abuse of other prescribed medications such as benzodiazepines for comorbid anxiety issues. Some MAT facilities will do a random monthly pill count for outside meds on an ongoing basis for more thorough monitoring, but will do an extra one during a bottle recall.

To further monitor for diversion issues, pharmacists and physicians at MAT facilities may utilize what’s known as the PDMP, which is a pharmacy database. This is the third protocol. The PDMP allows a pharmacist to run a patient’s information through the database to obtain information regarding a patient’s current prescriptions. This assists in preventing dual enrollment of patients, which is illegal. (Dual enrollment is when a patient is either concurrently enrolled in multiple MAT facilities, or when a patient is enrolled at an MAT facility and is also receiving prescriptions for opioids or for MAT medication at a private physician’s office.) It is especially important for MAT facilities to regularly use the PDMP because physicians’ offices cannot access prescription records for prescriptions patients receive at MAT facilities due to CFR 42.2 federal confidentiality regualtions for substance abuse treatment records. That is also the reason it is vital that MAT facilities make every effort coordinate care with patients’ physicians. Coordinating care with a patient’s physician ensures a higher level of patient safety, as the patient will be regularly monitored by both physicians.

Diversion may seem like an easy way to make extra cash, but it isn’t the primrose path it purports to be. Recently some states have passed bills allowing drug dealers and other people diverting their medications to be charged with murder if someone they sold substances or meds to happens to overdose and die. And it looks like similar bills being passed will be more common in the future as the number of prescription drug overdoses continues to increase. With the epidemic of prescription overdoses, it may behoove physicians with private practices to begin instituting protocols similar to those used in MAT facilities to minimize overdoses and diversion. First, do no harm. Where have I heard that before? Hmmm.

An Ounce of Prevention

“An ounce of prevention is worth a pound of cure.”    ~Ben Franklin

Shi…oops, I mean, stuff happens. I’m referring to relapse, specifically. Relapse is a part of the recovery process. It is a crappy part, but a part nonetheless. It is extremely rare to have a patient enter treatment and stay on the straight and narrow without a single relapse at some point in his/her treatment episode. I state this fact not to give patients an excuse to relapse, but to help to avoid the guilt and shame that keep patients using illicit substances once they do relapse. Relapse, like shi…stuff…happens.

Typically when people make the decision to enter substance abuse treatment, they are “gung ho” about making changes and are “all in” regarding their recovery. In the field we call this the Pink Cloud stage. Being excited about recovery is a very good thing; the problem lies in the ennui that comes after the Pink Could stage ends and everyday normal sets in. When that Pink Cloud lifts, everyday normalcy can seem…boring, despite being exactly what they expressed they wanted most when entering treatment.

Education regarding what to expect throughout each stage of treatment is the best defense a patient can have to protect his/her recovery. Any counselor or addictions therapist worth his/her salt will arm patients with adequate knowledge from the very start of treatment. After all, it is easier to handle situations if one is expecting them and has a plan of action to deal with them when they arise. This should include identifying the individual triggers for illicit substance use. Knowing the things that make a patient want to use, and having a plan of action to avoid those things and for how to handle them when they are unavoidable, are important elements of any treatment plan.

For anyone in recovery, it is also important to have support outside of the treatment setting. This entails more than simply finding a sponsor. This means changing the people that one surrounds oneself with, which can be a painful process. It means cutting off people that are damaging to one’s recovery, even if they are viewed as friends. It means not frequenting the same places that led/lead to using, or that contain people that use. One needs to change one’s playmates as well as one’s playground. There are many avenues to finding recovery support. A simple online search can be a good starting point for finding support meetings in one’s area such as  A.A., N.A., Celebrate Recovery, etc. Any treatment center should also be able to provide referrals upon request. Regardless of where it’s found, outside support is essential for anyone in recovery.

Recovery is never easy. Few things in life that are worth having are. One of the most awful aspects of addiction is that it is fatal if left untreated, so the choice should be easy, even if recovery itself is not. The choice is yours: life or death. What’s it gonna be? I hope you choose life. There are many beautiful things left to see and do. There are people that need you. You are here on this earth for a reason. You are still here because you are meant to make a difference to someone. That is why we are all here. That is why we all have differing struggles and different talents, to aid each other in this place and on this journey, until we reach our final destination. And we don’t need to do it alone. That in and of itself is a beautiful thing, even when the world is not. Choose life; there is more beyond the struggle.

If Something Doesn’t Change, Things Remain the Same (aka “Duh”)


I hear it all the time; on an almost daily basis. “Why does all this bad crap keep happening to me?” The therapist in me recognizes the external locus of control. For some reason people do not recognize the simplicity with which change can occur in their lives. In Catholicism we refer to it as “avoiding the near occasion of sin.” The concept is very similar; don’t put yourselves in a situation in which bad consequences are likely to occur.

Spelling out for people why “all this bad crap” has happened seems to make a light bulb go off. Recounting the series of events and bad decisions that have lead up to the present moment seems to bring about an “aha” moment. But why? Why did the potential for these bad consequences not occur to the person prior to thinking and acting in ways that lead to the bad consequences? The initial response when I try to point out to the person why things have unfolded in this particular way is indignation. “How dare you suggest that I caused this to happen to myself?” But then, the “aha” happens. Then the “wow, how did I not predict that?” moment occurs.

I think that the way society promotes instant gratification has a lot to do with the problem. Because people want what they want right now, they do not bother to think any further than how to get it. If people would visualize the scene and play it all the way through to the end, realistically calculating the potential for things to go wrong, they may get better final results and avoid the mess that ensues by not doing so. For instance, if I am on parole, and want to catch up with my friend, Jimmy, who is also a felon and a known drug dealer, and I decide to run over to his house and have a drink or two, which leads to snorting a line off of his glass coffee table and then getting into a fistfight with his girlfriend because she was also drinking and did a line and doesn’t like how Jimmy looked at me while I was leaning over the table, I shouldn’t be surprised when the cops are called by the neighbors who hear the ruckus, and I end up back in lockup with my parole violated. How does the famous historical quote go?… I think it was George Santayana who said it; and I’m paraphrasing…”Those who do not learn from the mistakes of the past are destined to repeat them?” Hmm, I think he’s got something there.

So… I guess the answer lies in learning to think before we speak or act. It lies in learning to delay gratification. It lies is learning to contemplate potential outcomes, both positive and negative, prior to acting. So breathe…and think…and then proceed.

Methadone Madness


Originally Published (by me) on LinkedIn on August 26, 2016

Admit it. You had an image of that God-awful documentary Reefer Madness in your mind didn’t you? …And…you already associated the context of that with your errant notions regarding what you think you know about methadone. I’m telling you that if you think that methadone is evil, you’re wrong.

Methadone maintenance has been the red-headed stepchild of substance abuse treatment options for many years. It has received a really bad rap and doesn’t have a very good reputation or public image. It’s time that people learn the truth about methadone and how many lives it saves.

Methadone Maintenance Treatment is for people that have been dependent on opioids for at least a year. That does not mean using opioids for a year; it means dependent on opioids for a year. Opioid withdrawal symptoms include sweating, hot flashes, chills, watery eyes, runny nose, excessive yawning, goose bumps, muscle pain, headache, nausea, diarrhea, vomiting, crawly skin, irritability, anxiety…the unpleasant list goes on. Suffice it to say that opioid withdrawal is like the very worst case of flu you have ever had multiplied by a factor of 12, and it doesn’t relent. Imagine feeling that way and knowing that with one phone call to a friend of yours, who might happen to have some of his leftover pain pill prescription from having a tooth extracted and might agree to spot you some, you could feel better in a matter of about 15 minutes. Hmm, let’s see…flu symptoms…or…take a couple of pills and feel normal again? No brainer, huh?

This is the dilemma people with Opioid Use Disorder face daily. They can be hellaciously ill and in bed, unable to be a parent, or employee, or functional anything, or they can score a few pills (or fentanyl, or heroin) and be normal…for a few hours anyway. Therein lies the rub: you have to amass enough medication to keep you normal. That’s what the “chase” is all about. You chase more pills in hopes of having a sufficient amount to keep you functional so that you can be whoever it is you are required to be. That is what keeps you using. You want to stop, but you don’t have the time or the inclination to be sick for very long. So you get a few pills, or grams, or whatever “just to get you through the day.” Then you’ll quit…later. The problem is, tolerance builds and the amount you used to take to be fine, no longer works, and you need more at a time to keep you fine. This costs more money, and more of your time. Then, the more you use, the more your tolerance builds, and the more you need. The other problem is, at some point you’ll reach your fatal dosage.

Methadone has been around for a really long time, and has been intensely studied and tested, and retested. Can it be abused? Yes, like a lot of helpful medications, it can be abused. Does that mean it isn’t suitable for use? No. Methadone is a miracle drug for many, many people suffering from Opioid Use Disorder. When patients come into a clinic for treatment, they are evaluated for their appropriateness for the program, and if so, they see the clinic physician, and are started on an initial dosage, which cannot exceed 30 mgs on their first day. They are required to attend the clinic daily to have the effectiveness of their dosage assessed and adjusted up or down as needed, to be monitored for signs of sedation or possible over-medication, and to begin treatment planning and counseling.

The initial goals of treatment include harm reduction and stabilization of the medication. Stabilization refers to the point at which the patient’s dosage keeps him/her from craving the drug of choice and alleviating withdrawal symptoms for a 24 hr period. Stabilization takes time. Methadone stays in the system (i.e., will keep a patient from withdrawal symptoms and cravings) for 24-36 hours. (It may stay in the system regarding showing positive on a drug screen for much longer than that.) This is the reason for the initial dosage not exceeding 30 mgs, and the reason that the dosage has to be adjusted slowly, in order to avoid overdose. It is also crucial for a patient to be educated on the dangers of potentiation. Potentiation refers to two or more substances increasing the effect of each other when consumed together. Certain substances potentiate each other, including opioids, benzodiazepines (like Xanax, Valium, or Ativan), alcohol, and barbiturates (like Phenobarbital, or Fiorocet). Basically, it means that taking two of these together leads to an equation of one plus one equals six, or eight, or ten. The amount of medication in the system is exponentially increased, and this substantially increases the risk of overdose and death. The risk of overdose is highest during the stabilization period because a patient who may not yet be getting 24 hours of relief can be tempted to supplement his/her methadone with other substances in an attempt to get additional relief. This is why most clinics require a new patient to see the counselor daily in order to learn about what to expect to feel physically, emotionally and psychologically while they are stabilizing, and to learn how to manage symptoms without resorting to illicit substance use.

Patients in Methadone Maintenance Treatment are required to submit to random weekly urine drug screens to monitor whether they are still using other illicit substances or alcohol, until they show compliance in the program as evidenced by having an observed urine drug screen whose results indicate no illicit substance use. (An observed drug screen is one where a counselor of the same sex as the patient goes into the restroom with the patient to ensure that the urine sample given is authentically that of the patient, and that the urine has not been obtained and brought into the facility.) If they show compliance for a period determined by the facility (usually for a minimum of 30 days), the patient is then placed on a random monthly drug screen schedule, where he/she is asked at a random and unannounced point once each month to provide a sample. If he/she continues to test positive for illicit substances after the 30 days, he/she is required to remain on a random weekly drug screen schedule to closely monitor the illicit use and to provide more interventions as needed.

So, now you know a bit about Methadone Maintenance Treatment and how programs work. I can hear you saying, “But these patients are just trading one drug for another.” That’s not the whole story. After years of using and/or abusing opioids, a person’s opioid receptors become dysregulated. Methadone works on a patient’s dysregulated receptors to normalize the patient. Patients are not getting high in treatment, they are getting normal. You wouldn’t tell a diabetic person, “Just lock yourself in a room for ten days, tough it out, and you’ll be fine. You won’t need that insulin anymore.” I can hear you saying, “That’s different.” It isn’t. Insulin normalizes the system of the diabetic person and keeps him/her from being sick. Methadone normalizes the system of the person with Opioid Use Disorder and also keeps him/her from being sick …with withdrawals. You say, “But the opioid addict did that to themselves. He/She shouldn’t use medication.” Okay, then, I guess you also believe that someone who smokes like a chimney for a lot of years and gets lung cancer shouldn’t get treatment either then?  …Thought provoking, isn’t it?

Addiction is a disease. It is primary, chronic, and fatal if left untreated. It bears repeating…FATAL IF LEFT UNTREATED. In the case of Opioid Use Disorder, it is a disease with horrible physical symptoms. Methadone makes people suffering from this disease functional and productive members of society again. They are better spouses, better parents, better family members, better employees. I promise you that you know someone on methadone, and you probably don’t even realize that you do. I work at a Medication Assisted Treatment facility that offers methadone and suboxone. We treat people of every kind, all races, religions, economic backgrounds… Addiction is an equal opportunity destroyer. It can affect anyone, no matter your upbringing, your intelligence, your socioeconomic status. For Opioid Use Disorder, Methadone Maintenance Treatment has the highest efficacy, and the best outcomes. I have seen it change so many lives for the better.

If you know anyone suffering from Opioid Use Disorder, you now have the knowledge to help them to get the help they need. You may locate a clinic by going to the SAMHSA website (, and clicking on the treatment locator. You can put in your location, and then specify Methadone or Suboxone (buprenorphine) services on the pull-down menu once you open the link. You’ll want to ask the facility if they are CARF accredited before you seek admission.

Thank you for your time and attention. I appreciate your consideration.

-Tricia Gordon CAC II, NCAC II

Keepin’ It Real

Just a snippet about me. Who I (think I) am, what I do, and why I am the way I am.

I’ve been a Clinical Addictions Counselor working at two different methadone clinics since 2008. Let’s just say I’ve seen a few things. And let me thank God right now for my sense of humor, because without it, I wouldn’t have made it this far! I’m currently a Clinical Supervisor at a methadone clinic, which means I’ve been doing this long enough to know what I’m doing, to know sh…poop from Shinola, and to have been promoted.

So…I’m gonna get on my soapbox for a minute… People suffering from addiction …argghhh… I mean, Substance Use Disorder (thanks for the mouthful, DSM 5, I truly appreciate that) deserve the same dignity and respect as everyone else. In general they consist of good people suffering from a bad disease. Yes, addiction IS a disease. (Even the medical community has realized this and affirmed it now. Check out the updated ASAM definition of addiction. Go ahead, google it. I’ll wait.) It is a disease that is chronic, progressive, and FATAL IF LEFT UNTREATED! There are many reasons someone may become addicted. Yes, those people choose the behaviors that lead to their addiction, but once they become addicted, there is no going back. There is no cure, only management. And it doesn’t take very much effort to go from using drugs recreationally to becoming addicted. If something makes us feel good, we humans want more of it, and want it more often. It seems that we’re almost wired for addiction…whether it’s to drugs and alcohol, or something else, like food, technology, sex…The difference is, drug addicts and alcoholics can’t as easily HIDE their addictions as can those addicted to those other things. And for some odd reason those people addicted to those other things don’t get the same bad rap as those addicted to drugs or alcohol. So maybe our instant judgement of those we so casually label “junkie”  warrants reconsideration. People who suffer from addiction (sorry dsm 5, it’s an easier term to use) need help and support to get their lives together, not criticism and judgment.

Okay, I’m done. I’ll get off my soapbox now. For a short while anyway.